What is the typical appearance of conjunctival metastases (mets)?

Appearance of Conjunctival Metastases

Conjunctival metastases typically appear as solitary, yellowish masses on the bulbar or palpebral conjunctiva, often accompanied by intense conjunctival injection, and should be considered in any patient with a history of systemic cancer presenting with a new conjunctival lesion. 1, 2

Clinical Characteristics

Color and Morphology

• Yellow coloration is the most common presentation, occurring in approximately 70% of cases, though lesions may also appear red (20%) or brown (10%) 2
• The lesions can present as flat or nodular masses on the bulbar conjunctiva (most common), palpebral conjunctiva, limbus, or forniceal conjunctiva 1, 2
• Sebaceous carcinoma, which can mimic metastatic disease, may appear as a subconjunctival multilobulated yellow mass or yellowish discoloration of the tarsal plate 1, 3

Associated Clinical Signs

• Intense bulbar conjunctival injection is a characteristic finding that should raise suspicion for neoplastic disease 1
• Conjunctival scarring may be present 1
• Mucopurulent discharge can occur 1
• The lesions are typically solitary (80% of cases) rather than multifocal 2

Primary Tumor Sources

• Breast carcinoma is the most common primary source (40% of cases), followed by lung cancer (20%), cutaneous melanoma (20%), and laryngeal carcinoma 2
• Metastases typically appear 8-130 months after the primary tumor diagnosis, with a mean of 44 months 2

Critical Diagnostic Features Requiring Urgent Evaluation

Warning Signs

• Enlargement of the lesion, development of blood vessels, or thickening warrant immediate biopsy 4
• Recurrence in the same location, particularly in elderly patients with history of multiple excisions 4
• Any conjunctival mass in a patient with prior systemic cancer should be presumed metastatic until proven otherwise 2

Evaluation Approach

• Slit-lamp biomicroscopy is mandatory to assess location, depth, elevation, and vascular characteristics 4, 3
• Biopsy should be performed for atypical features or in patients with known systemic malignancy 4

Clinical Context and Prognosis

• Conjunctival metastases indicate advanced systemic disease, with 80% of patients having concurrent metastases to other ocular structures or organs 2
• Mean survival after diagnosis of conjunctival metastasis is only 9 months (range 2-26 months), though one case report documented death within 3 weeks 2, 5
• The presence of conjunctival metastasis represents a poor prognostic indicator requiring immediate systemic evaluation and oncologic consultation 2, 5

Common Pitfall

• Do not misdiagnose sebaceous carcinoma or metastatic disease as chronic blepharoconjunctivitis, as this delays appropriate treatment and worsens outcomes 1, 6